International
Couples Fellowship

Client Intake & Consent Form

To protect both the International Couples Fellowship (ICF) and the professionals volunteering their time, it is vital to have a signed Client Intake & Consent Form. This form ensures couples understand that ICF is a facilitator, not a medical clinic, and establishes clear rules for confidentiality.

Pro-bono fellowship
Confidential
~5 minutes

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Step 1 of 4

Participant Information

Who will be attending the fellowship sessions?

Partner A Name

Partner A Date of Birth

Partner B Name

Partner B Date of Birth

Address

Best Contact Phone

Your confirmation copy is sent here.

Emergency Contact Name / Phone

Step 2 of 4

Relationship Overview

A short summary helps us pair you with the right volunteer.

Years Together / Married

Main Challenge

Communication, trust, finances, parenting, in-laws…

Goal For These Sessions

Step 3 of 4

Terms of Service & Disclosures

Tap each item to acknowledge. All five are required.

0 of 5 acknowledged

1. Nature of ServiceI understand that ICF provides educational and supportive fellowship. While we may be paired with licensed professionals, these sessions are provided pro-bono and do not constitute a formal doctor-patient or attorney-client relationship with ICF itself.
2. ConfidentialityInformation shared is confidential. However, by law, confidentiality must be broken if there is a threat of harm to self or others, or suspected abuse of a child or elder.
3. The "No Secrets" RuleIn couples counseling, the professional may decline to hold individual secrets (e.g., undisclosed affairs) from the other partner if it hinders the healing of the union.
4. No Guarantee of OutcomeWhile we provide tools for success, ICF and its volunteers cannot guarantee specific results or the preservation of the marriage.
5. Release of LiabilityI agree to hold ICF and its volunteer professionals harmless from any claims or damages arising from the advice or services provided during this fellowship.

All five disclosures must be acknowledged before submitting.

Step 4 of 4

Signatures

Draw your signature in the box below using your mouse or finger.

Partner A Signature

Sign here

Partner B Signature

Sign here

By submitting, both partners confirm the information above is accurate and that they consent to the terms of this fellowship.

Stored securely · shared only with your assigned volunteers

Confidential · 0% complete